Medicine is a complex craft. Acute medicine is more complex. Excellence is delivering effective acute care depends on recognising the broad base of basic sciences, clinical experience, and results of clinical trials. Central to all decisions has to be how these will benefit the patient – both in the short term as well and longer term so that survivors of acute illness are left with the best possible outcome for that patient, their caregivers and the community at large. This is a daunting concept under time-limited, information-limited conditions. Clinicians are often left with uncertainty about the impact of decisions and rely on short-term surrogate measurements to justify treatment options. Consequently, assessing outcomes are invariably confounded by associations that bear little relationship to causation or biological plausibility. Such confounders are often demonstrated in observational studies and RCTs with low levels of internal validity, particularly those conducted in single centres and/or driven by protagonists of a particular intervention. Carefully conducted RCTs with high levels of internal validity – those that produce believable results from rigorous study design and those that produce results that are generalisble to specific patient populations remain the only way to mitigate bias and produce clinically-relevant answers to improve patient-centred outcomes. Critical Care Medicine leads the way in producing high-fidelity RCTs that have fundamentally changed clinical practice, not only in terms of producing better patient-centred outcomes, but also by producing unequivocal evidence to stop or avoid using of previously harmful treatments that had been enthusiastically embraced by clinicians and guideline developers. Such examples of benefit include the CRASH-2 and ARDS-net trials, and of preventing harm, the SAFE, NICE-SUGAR, RENAL, CHEST, DECRA and FEAST studies among others. The net impact of these pivotal trials has been the prevention of millions of deaths and the saving of millions of dollars. Such is the basis of GOOD clinical practice and these trials must be seen as a source of knowledge, science and pride … that ultimately improve patient outcomes .

CON:

This speaker is pretty certain he is going to lose...but he's going to go down fighting. He will argue against the mighty Dr John Myberg (whom, incidentally, he admires mightily). RCTs do certainly matter, but clinical judgment and prompt bedside attention matters far more. Moreover, RCTs so often fail to address the questions that really matter. RCTs also commonly fail to improve quality, effectiveness, safety, and reliability in modern complex acute medical care. A vote against the blinkered focus on RCTs is a vote for better (not biased) patient care. Myberg and his myopics must be defeated...come join me!

The management of severe traumatic brain injury (TBI) has undergone extensive revision following evidence that longstanding and established practices are not as efficacious or innocuous as previously believed. Very few specific interventions have been shown to improve outcome in large randomized controlled trials and, with the possible exception of avoidance of hypotension and hypoxaemia, most are based on observational studies or analysis of physiology and pathophysiology. Further, the substantial temporal and regional pathophysiological heterogeneity after TBI means that some interventions may be ineffective, unnecessary or even harmful in certain patients at certain times.

Improved understanding of pathophysiology and advances in neuromonitoring and imaging techniques have led to the introduction of more effective and individualised treatment strategies that have translated into improved outcomes for patients. In particular, the sole goal of identifying and treating intracranial hypertension has been superseded by a focus on the prevention of secondary brain insults using a systematic, stepwise approach to maintenance of adequate cerebral perfusion and oxygenation. As well as being used to guide treatment interventions, multimodal neuromonitoring also gives clinicians confidence to withhold potentially dangerous therapy in those with no evidence of brain ischemia/hypoxia or metabolic disturbance.

The days of blind adherence to generic physiological targets in the management of severe TBI have been replaced by an individualised approach to optimisation of physiology which has translated into improved outcomes for patients.

Mark -CON- :

The New England Journal of Medicine has published a number of articles recently that demonstrate no benefit from classic neurotrauma interventions (ICP monitoring, cooling, decompression). This is because factors such as ICP and CPP are associated with bad outcome by association rather than causation. This debate will demonstrate that critical care just complicates things and it is high time for the randomised trial between the very best Neurocritical care and NOB therapy (Naso-pharyngeal, Oxygen and a Blanket).

Ever wondered if prehospital doctors add LITTLE or LOTS of value in trauma? Ever wondered if an Amazonian Warrior Girl can take on a Kangaroo Aussie Military Man? If you are looking for level-1 evidence on either of these topics, you are in the wrong room! But stick around, it will sure be entertaining & enlightening. Show me anyone who doesn't like a full-contact bare knuckle debate. Bring it on!

Resuscitation of the critically ill trauma patient involves a myriad of high-stakes, time-sensitive management decisions. The landscape is shifting rapidly: new evidence on hemostatic resuscitation and component therapy in hemorrhagic shock, peri-arrest point-of-care ultrasound, novel approaches to resuscitative thoracotomy and trauma RSI have at once clarified and muddied the waters. In this rapid-fire, case-based session, Petro and Hicks will debate some of the recent and potentially practice changing literature to assist with key inflection points in the care of the sickest -- and sometimes deadest -- trauma patients, and engage in some trauma dogmalysis in the process.

The application of ‘CPR-for-all’ is the ultimate evidence drift. A treatment that is completely appropriate for dropping dead whilst running a marathon has almost no place in acute healthcare facilities where chronic irreversible complex co-morbidities abound. 90% of doctors would not choose CPR for themselves, yet 100% are trained in how to administer it to patients. Defaulting to ‘CPR-for-all’ removes a patients’ ability to provide informed consent for assault whilst they die from another disease. Remember - 2 weeks in ICU can spare you 5 minutes of difficult conversation.

Sara -CON- :

Across the globe, patients are assumed to be full code to allow for prompt resuscitation, until code status can be discussed and clarified. There are numerous excellent reasons for this. Can you imagine if our systems decreed that DNR was the default? “Let’s not shock that VF, until we can clarify his code status.” Or, “let’s not resuscitate that child, after all, DNR is the default and her mother isn’t here yet!” Making DNR the default is not a good solution to ICU or hospital over-crowding. Let’s not mandate DNR, let’s mandate having reasonable code discussions early and often.

In a 2 min rant about medical tribalism, Dr. van der Velde questions which medical specialty, if any, owns prehospital physician response. What is more important: skillset or specialty? Is there a role for tiers of physician response? Is there a future in a stand-alone specialty?